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Tax Rebate Form Hvac

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					                                    1 RESIDENTIAL
                               201EFFICIENCY HEATING AND COOLING SYSTEM REBATE
                               HIGH
                               Valid for customers who purchase a qualifying high efficiency heating and/or cooling system installed March 1, 2011 through February 29, 2012. All rebate
                               requests must be postmarked no later than March 31, 2012. Total incentive cannot be more than 50% of the total installation cost of the qualifying high
                               efficiency heating and/or cooling system.
                               TO RECEIVE YOUR REBATE, READ THE PROGRAM REQUIREMENTS ON REVERSE BEFORE PROCEEDING.
                               INSTRUCTIONS: Please fill out this form completely and mail it to the address below. You must include a copy of the contractor’s invoice, listing the
                               condenser, coil and fan model and serial numbers, the purchased equipment type, the AHRI certificate verifying system as a MATCHED ASSEMBLY
                               and a copy of your recent electric utility bill. A matched assembly is a model combination that is listed in the AHRI Directory of Certified Equipment.
                               A matched assembly shall also include the air handler; furnace; or other component that is used to determine the rating according to
                               ANSI/AHRI STANDARD 210/240-2008. These items must accompany each incentive Application.
                               Mail to: EFI – CT HEHC Rebates, 40 Washington Street, Suite 2000, Westborough, MA 01581



 Customer Information
(Please Print) First Name             Last Name                                                    Telephone                            Email


Address (where equipment was installed)                                                            Electric Utility (Check One)         Electric Account Number (as stated on bill)
                                                                                                    n CL&P          n UI

City                                                                  State     Zip                Type of Installation (Check One)
                                                                                                    n New Installation (New Home)               n New Installation (Existing Home)
Mailing Address (if different from above)                                                           n Replacement (of Existing System)

                                                                                                   How did you hear about this Program? (Check One)
City                                                                  State     Zip
                                                                                                    n Radio           n Print Ad         n Manufacturer Ad
                                                                                                    n Bill Insert     n Website          n Other


 Equipment Information (This Section To Be Completed By Contractor)
 EQUIPMENT
 C = Central A/C                            Manufacturer/              Model Numbers                                                                     # of          AHRI             Total
 H = Heat Pump         Install Date            Brand                 (Condenser, Coil & Fan)          Tonnage         SEER        EER           HSPF     Units        Ref. No.        Incentive*
       Example: C        12/31/2011           XYZ, Inc.                 Condenser Model                    2           14.5        12            8.2        1          1234567          $250
                                                                              Coil Model
                                                                              Fan Model




 Contractor Information                                                                             Supporting Documentation Checklist
Contractor Name                                 Contractor License Number
                                                                                                     m Completed 2011 Residential High Efficiency Heating and Cooling System Rebate Form
                                                                                                     m Contractor Invoice and Paperwork Listing:
Address                                                                                                     m Purchase Price                 m Condenser Make & Model Number
                                                                                                            m Equipment Type                 m Coil Make & Model Number
City                                                                  State     Zip                         m Date of Purchase               m Fan Make & Model Number
                                                                                                     m AHRI Certificate
                                                                                                     m Recent Electric Bill
Telephone Number                                Fax Number
                                                                                                     Please send your completed 2011 Connecticut Residential High Efficiency
 (           )                                    (         )                                        Cooling System Rebate Application to: EFI-CT HEHC Rebates,
E-mail Address                                                                                       40 Washington Street, Suite 2000, Westborough, MA 01581
                                                                                                     1-877-364-4217



 SIGN HERE
     By signing this form below, I certify that all the information described in the High Efficiency Heating and Cooling System Rebate Program Application and all the documents provided
     with this Rebate Application are accurate and true and that I have read and understand the High Efficiency Heating and Cooling System Rebate Program Guidelines. By signing this form
     I further certify that the qualifying System is installed for use in the Connecticut residential address stated.

     Customer Signature (Required)                                     Date:                       Contractor Signature (Required)                                       Date:



                                              You may be eligible for federal tax credits. Please refer to www.energystar.gov for more information.
                                         1 RESIDENTIAL
                                    201EFFICIENCY HEATING AND COOLING SYSTEM REBATE
                                    HIGH
   ELIGIBILITY: Incentives are available to all CL&P and UI residential electric service customers. Equipment must be installed by a licensed contractor in the service territory
   of the participating electric utility. Eligible systems are: electric central air conditioning and air source heat pump systems with MATCHED ASSEMBLIES
   in which both the condenser unit and the evaporator coil are installed simultaneously. A matched assembly is a model combination that is listed in the AHRI
   Directory of Certified Equipment. A matched assembly shall also include the air handler; furnace; or other component that is used to determine the rating according to
   ANSI/AHRI STANDARD 210/240-2008.


APPLICATION OFFER: This program covers products purchased and installed on or                                 FORWARD CAPACITY MARKET AND CLASS III CREDITS: By signing this
after March 1, 2011 through February 29, 2012. Details of this program, including incentive                   document and as a condition to receiving a rebate pursuant to this program, customer
levels, are subject to change or cancellation without prior notice. This Application with                     hereby assigns to its participating electric utility, either CL&P or UI (as the case may be),
required documentation must be postmarked by March 31, 2012. Please call 1-877-WISE-                          any and all payments, benefits and/or credits in connection with the Forward Capacity
USE for details.                                                                                              Market or any currently existing or successor or replacement markets, (including, but not
PROOF OF PURCHASE: A contractor’s invoice listing the date of purchase, condenser,                            limited to, any and all “LICAP”, “ICAP”, transitional credits or payments or any and all
coil and fan model and serial numbers, the purchased equipment type and make, the                             other capacity-related credits, payments and/or benefits for which Customer is eligible)
AHRI certificate (a published manufacturer’s certificate indicating the installed assembly                    and that are associated with or applicable to customer’s participation in the Residential
was tested under AHRI test conditions and includes the SEER, EER and COP ratings is                           High Efficiency Heating and Cooling Rebate Program. Customer hereby assigns to either
acceptable in lieu of the AHRI certificate) verifying system as a matched assembly, and                       CL&P or UI (as the case may be) all of its right, title and interest in and to any and all
your recent electric utility bill must accompany each incentive Application.                                  such capacity payments, credits and/or benefits and shall take any and all action, including
APPLICATION: This Application must be filled out completely, truthfully and accurately.                       executing and delivering any and all documents and/or instruments, as requested by either
The Customer and Contractor must each sign the completed Application and it must be                           CL&P or UI (as the case may be) to evidence the same. Forward Capacity Market means
submitted along with the Proof of Purchase requirements listed above.                                         the market for procuring capacity pursuant to ISO-NE Tariff, FERC Electric Tariff No. 3,
PAYMENT: Please allow up to 90 days for payment. Payment processing may take longer
                                                                                                              Section III, Market Rule 1, Section 13, any modifications to the Forward Capacity Market,
if information is missing on the Application. Please Call EFI at 1-877-364-4217 if you                        or any successor or replacement market/capacity procurement process.
have any questions about your rebate incentive.                                                               In accordance with the Department of Public Utility Control’s (“DPUCs”) September
APPROVAL AND VERIFICATION: CL&P and UI reserve the right to verify sales
                                                                                                              29, 2008 decision in Docket No. 05-07-19RE01, DPUC Proceeding to Develop a New
transaction and to have reasonable access to your residence to inspect the system                             Distributed Resources Portfolio Standard (Class III) – 2007 Revisions, (as supplemented
installed under this Program prior to issuing incentives for up to one year after date of                     by the Department February 11, 2010 decision in Docket No. 05-07-19RE02), customer is
application.                                                                                                  not to receive or retain any Class III renewable energy credits in connection with the High
                                                                                                              Efficiency Heating and Cooling Incentive Program and Customer hereby acknowledges
TAX LIABILITY: CL&P and UI will not be responsible for any tax liability that may be
                                                                                                              and agrees the same. Customer further acknowledges and agrees that such credits shall
imposed on the Customer as a result of the payment of rebate incentives.
                                                                                                              be retained by either CL&P or UI (as the case may be) for the benefit of their customers
ENDORSEMENT: CL&P and UI do not endorse any particular manufacturer, contractor,
                                                                                                              through the Connecticut Energy Efficiency Fund. In the event that the DPUC amends or
vendor, product, retailer or system design in promoting this program.                                         modifies the allocation of Class III conservation credits as reflected in its September 29,
LIMITATION OF LIABILITY: CL&P and UI’s liability is limited to paying the rebate                              2008 decision, then the allocation of such credits utilized by either CL&P or UI (as the
incentive specified. CL&P and UI are not liable for any consequential or incidental                           case may be) shall be the allocation in effect (per the applicable DPUC decision) on the
damages, or for any damages in tort connected with or resulting from participation in this                    date that the Customer submitted its Rebate Application documents to either CL&P or
program.                                                                                                      UI (as the case may be).
OWNER’S CERTIFICATION: Owner certifies that he/she has purchased and installed                                Customer further acknowledges and agrees that customer is not to retain or receive any
the equipment listed on the other side of this Application at the defined location.                           environmental credits or benefits that may be ascribed or attributed from time to time
Owner agrees that all information is true and that he/she has conformed to all program                        to customer’s participation in the High Efficiency Heating and Cooling System Incentive
and equipment requirements listed.                                                                            Program and any and all such benefits or credits shall be retained by either CL&P or UI
WARRANTIES: CL&P AND UI DO NOT WARRANT THE PERFORMANCE                                                        (as the case may be) for the benefit of their customers through the Connecticut Energy
OF INSTALLED EQUIPMENT, EXPRESSLY OR IMPLICITLY. CL&P and UI makes no                                         Efficiency Fund.
warranties or representations of any kind, whether statutory, expressed, or implied,
including without limitations, warranties of merchantability or fitness for a particular
purpose regarding the heating and/or cooling system or services provided by a
manufacturer, contractor or vendor. Contact your Contractor for details regarding
equipment performance and warranties.


                                                                Minimum Efficiency Levels / Incentive Schedules
 Central Air Conditioning                                                                                                                                                    Incentive Per Unit*

 AHRI1 Rated Unitary Air Conditioning and Split Systems                                14.5 SEER 2 / 12 EER 3                                                                $250

 AHRI Rated Central Air Conditioning Packaged Systems                                  14 SEER / 11 EER                                                                      $250/Home

 AHRI Rated Air Source Heat Pump Split Systems                                         14.5 SEER / 12 EER / 8.2 HSPF4                                                        $250

 AHRI Rated Air Source Heat Pump Packaged Systems                                      14 SEER / 11 EER / 8.0 HSPF                                                           $250/Home

1 AHRI – Air Conditioning, Heating and Refrigeration Institute. All equipment must be rated in the AHRI Air Conditioners and Air Conditioner Coils or Heat Pumps and Heat Pump Coils directories. Both can be found
online at www.AHRIdirectory.org.
2 SEER – Seasonal Energy Efficiency Ratio 3 EER – Energy Efficiency Ratio               4 HSPF – Heating and Seasonal Performance Factor

* Total incentive payment not to exceed 50% of the total installation cost of the qualifying high efficiency heating and/or cooling system.
  Funding for this rebate program is limited to the period indicated or while funds last.
   Ductless & Geothermal Heat Pump Applications available at www.uinet.com or www.cl-p.com

				
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Description: Tax Rebate Form Hvac document sample